Description
Our patient with ccTGA had previously undergone VSD patch closure and pulmonary valvotomy as an infant and then later palliated with pulmonary artery banding. He subsequently developed worsening heart failure and was listed for heart transplantation due to progressive systemic RV failure. Following ring annuloplasty of the systemic tricuspid valve, we proceeded to systemic RVAD implantation. As per routine, placement of the HM3 inflow cannula to the RV apex was guided by transesophageal echocardiography (TEE) but optimal image acquisition was challenging. The inflow cannula was to be placed anterior and lateral to the true apex of the systemic RV. The ventriculotomy created by the VAD coring device overrode into the ventricular septum and was hidden underneath the inflow cannula ring (Fig 1A). With initiation of RVAD at 4L/min, the patient became severely hypoxic with a PO2 of 45-50 mmHg secondary to the large pulmonic to systemic circulation shunt (i.e right-to-left) which was also identified on TEE and epicardial echocardiogram. Cardiopulmonary bypass (CPB) was re-initiated and the inflow cannula was removed, revealing a large iatrogenic VSD at the cannula insertion point (Fig 1A ). The VSD was closed by bovine pericardial patch and the ventriculotomy was extended laterally to relocate the new RVAD sewing ring (Fig 1B ) using 2-0 Tycron sutures placed as an open technique. After CPB was weaned again, the patient initially remained cyanotic and echocardiography imaging identified a tiny residual VSD patch leak with right to left shunting as a potential cause of hypoxia. Due to the prolonged duration and complexity of the case, pursuing residual VSD closure was deemed unsafe. A trial of rescue of inhaled nitric oxide (iNO) was initiated which had the dramatic effect of increasing the arterial saturation from the 70% range to 90s. The patient was transferred back to the cardiovascular intensive care unit in stable condition and continued to demonstrate oxygen saturations >90%, even after weaning iNO and extubation from mechanical ventilation. There were no further issues with regards to either VAD support or saturations for our patient after surgery, and the patient was successfully bridged to transplant after 91 days of RVAD support.